Health workers who worked with chemo are being diagnosed with cancers possibly linked to those drugs

View full sizePaul Joseph BrownChelsea Crump kisses her mother Sue Crump goodbye after a visit in hospice care. Sue Crump handled chemo drugs for years and died of pancreatic cancer she believed was caused by her job.

By CAROL SMITH INVESTIGATEWEST

Sue Crump braced as the chemo drugs dripped into her body. She knew treatment would be rough. She had seen its signature countless times in the ravaged bodies and hopeful faces of cancer patients in hospitals where she had spent 23 years mixing chemo as a pharmacist.

At the same time, though, she wondered whether those same drugs -- experienced as a form of "secondhand chemo" over a career mixing them as a pharmacist -- may have caused her cancer.

Crump knew she had her own war on her hands. She wanted to live to see her 21-year-old daughter, Chelsea, graduate college.

And she wanted something else: She wanted young pharmacists and nurses to pay attention to her story.

Crump, who died of pancreatic cancer in September at age 55, was one of thousands of health care workers chronically exposed to chemotherapy agents on the job for years before there were even voluntary safety guidelines.

Now some of those workers are being diagnosed with cancers that occupational health specialists say could be linked to exposure to those same powerful drugs that saved hundreds of thousands of lives.

Studies as far back as the 1970s linked increased rates of certain cancers to nurses and physicians. Occupational health experts believe that's because when nurses, pharmacists, technicians and increasingly, even veterinarians, mix and deliver the drugs, accidental spills, sprays and punctures put them in close, frequent contact with hazardous drugs.

A just-completed 10-year study from the U.S. Centers for Disease Control, the largest to date, confirms that chemo continues to contaminate work spaces where it's used, and in some cases is found in the urine of those who handle it, despite knowledge of safety precautions.

Chemo agents -- powerful cancer-fighting toxins descended from deadly mustard gas first used against soldiers in World War I -- have been classified as hazardous by OSHA since the mid-1980s. Hazardous drugs are those known, or suspected to cause cancer, miscarriages, birth defects or other serious health consequences.

Jordan Barab, deputy assistant secretary of labor for OSHA, said in written response to questions from InvestigateWest that the agency doesn't have the resources to regulate workplace drug exposures, although it is concerned.

OSHA has no regulatory authority to enforce safety practices with fines or sanctions, other than a "General Duty" regulation to warn an employer if they see something that concerns them.

According to documents obtained by InvestigateWest through the Freedom of Information Act, OSHA has only once in 10 years cited any health care institution -- including hospitals, clinics, dental and veterinary offices -- for their handling of hazardous drugs under the General Duty regulation.

"There is no other occupation population (that handles) so many known human carcinogens," said Thomas Connor, a research biologist with the National Institute for Occupational Safety and Health. Connor has spent 40 years studying the effect of chemo agents on workers and is one of the lead authors on the latest study.

Tracing an individual's cancer to a particular exposure is difficult. It's one of the main reasons safety advocates have been thwarted in their efforts to tighten regulations.

But the ranks of those who have become symbols for increased safety includes pharmacists Bruce Harrison of St. Louis and Karen Lewis of Baltimore; veterinarian Brett Cordes of Scottsdale, Ariz.; and nurse Sally Giles of Vancouver, B.C.

Like Crump, all eventually got cancer, or in Lewis' case a pre-cancerous condition. Cordes was diagnosed four years ago at age 35. Giles was in her 40s, and Lewis and Harrison were in their 50s when diagnosed. All but Lewis and Cordes are now dead.

On an afternoon in May 2009, Crump sat in a coffee shop near her suburban Seattle home and perused a list of chemo drugs now deemed hazardous for health care workers to handle. She runs her fingers down the page. It's a long list: cyclophosphamide, doxorubicin, fluorouracil, methotrexate. And on.

"Yeah, I worked with all of them," she said.

Crump started at Swedish Medical Center in the early 1980s, before pharmacists used special protective "hoods" over countertops to contain spray and contamination. They didn't use gowns or gloves. They had no reason to think they should. Occasionally, drugs would spill on the countertops.

"We would wipe if off and throw (the towels) in the garbage," Crump said.

Most of the chemo came in vials, and workers transferred it into plastic IV bags. Sometimes there would be spray when they punctured the vials. Other drugs came in ampules, glass vessels sized for a single infusion.

"But the feeling at the time was -- whatever little vapors or splash -- it was such a low exposure through the skin, it was insignificant," Crump said.

That was a common attitude then -- and now, said Dr. Melissa McDiarmid, director of occupational health at the University of Maryland.

"So many people think it's just a 'little bit.' They don't understand, it's a little bit of something designed to be toxic, and to be highly absorbed biologically." A silent threat

Danish epidemiologists used cancer registry data from the 1940s through the late 1980s to report beginning in 1975 a significantly increased risk of leukemia among oncology nurses and later physicians. Last year, another Danish study of more than 92,000 nurses found an elevated risk for breast, thyroid, nervous system and brain cancers in nurses.

"It's been a silent threat for a long time with very little attention by the government," said Bill Borwegen, occupational health and safety director for the Service Employees International Union, the labor union that represents nurses nationally.

Chemotherapy agents, when dispersed in the air or onto surfaces, are invisible, difficult to clean, long-lasting, easily spread and capable of causing genetic damage. They've been found on the outsides of the drug vials shipped from manufacturers, on floors and countertops, on keyboards, garbage cans and door knobs.

Researchers at NIOSH, a division of the CDC, were so concerned, they issued an extensive alert about handling high-risk drugs. The 2004 guidelines urge strict precautions, including impervious chemo gowns, double-gloving, use of sophisticated "closed-system" devices and specialized ventilation hoods, face shields and respirators and clean rooms.

Ten years into Crump's career, reports of health effects related to chemo exposure surfaced in Europe, and health care workers started to adopt rudimentary safety procedures.

Her pharmacy manager took the warnings seriously and installed ventilated hoods considered state-of-the-art at the time. The trouble was the hoods were designed to keep chemicals sterile by blowing contaminants away from them and back out of the hood. That meant the worker standing outside the hood was still getting exposed, Crump said.

Lanny Turay worked in the same pharmacy as Crump and recalled many of the same experiences. He now manages pharmacy operations at Swedish Cancer Institute.

Safety practices have evolved over the years. Swedish now has a special dedicated area for mixing chemo and uses a different type of hood that no longer blows air back at the workers. Workers wear special gowns, gloves and sleeves, and take other precautions to keep chemo from spreading, he said.

Still, Crump wondered whether those early, ongoing exposures contributed to the cancers she and her peers got. She first recalled being alarmed after a pharmacy tech with whom she mixed a lot of chemo died at age 29 of a brain tumor. Around the same time, several colleagues experienced miscarriages.

Since that time, studies have shown an association between exposure to chemo agents and reproductive effects including miscarriage, birth defects and low birth weights. A 2005 survey found significant associations with infertility and miscarriage in nurses who handled chemo before the age of 25.

Nurses, who occasionally spill the chemo drugs on their clothing or splash it on their skin, had a greater chance of premature labor or having children with learning disabilities if they administered nine or more doses of chemo a day. "Now all these people about my age are getting cancer -- cervical, ovarian, prostate, endometrial, brain," Crump said. "All of us, at one time or another, worked with chemo -- we wondered, well, is there a connection?"

Safety advocates are especially worried about workers in smaller clinics, where awareness is not as high and expensive equipment may be less available.

There are more than 5.5 million workers involved in nursing, pharmacy, transport and cleanup of chemo waste. Of those, experts estimate about 2 million actually mix or dispense chemo. Those numbers will grow as cancer patients climb by a projected 50 percent in the next decade as the population ages.

In addition, chemo drugs themselves have found wider application -- in the treatment of arthritis, multiple sclerosis and other diseases.

Taking it seriously

On a sunny day in June 2009, Sue Crump has a list of things to do.

She needs to teach her daughter, Chelsea, about mortgages and schedule an appointment with a financial planner. They are going through boxes of old photographs. Crump has already outlived various prognoses.

Sue Crump died, surrounded by her family and her beloved dogs, in her own living room Sept. 13.

Shortly before her death, she said she hoped talking about her experiences would make a new health care worker pay a little more attention.

"Safety needs to be revisited," she said. "People don't take this seriously enough."

InvestigateWest is a nonprofit investigative news organization covering the Pacific Northwest. Find out more atwww.invw.org.